(Date)
(Name of Person Completing this Form)
(Title and Employer)
(Phone Number)
(Email Address)
(LPS Project Coordinator's Name),
Local Projects Section
Nebraska Department of Transportation
PO Box 94759
1400 Hwy 2
Lincoln NE 68509
Re:(Project Name)
(Federal Project No.)
Control No.
(Section, Township, Range, County Name)
Dear (Local Projects Section Coordinator's Name):
On behalf of (Name of LPA), our firm is submitting this Biological Evaluation to assist the Nebraska Department of Transportation in completing review of this project’s impacts pursuant to the Endangered Species Act, Bald and Golden Eagle Protection Act, and Fish and Wildlife Coordination Act.
1.Project Description
(see instruction document for details to include in this section)
2.Project Length and Detours:
a. What is the length of the proposed project?
b. What are the beginning and end points of the project?
c. Will the project require traffic to be detoured? Yes No
d. If Yes, will there be any construction activities or improvements to the detour
route? Yes No
e. Describe any detour improvements or construction activities:
3.The Activity Checklist (see instructions for requirements)
The Activity Checklist at the end of this document has been completed. Yes
4.Habitat Description
(see instructions for requirements)
5.Bald and Golden Eagle Habitat Description
(see instructions for requirements)
6.Fish and Wildlife Coordination Act
(see instructions for requirements)
7. Habitat Impacts
a. (see instructions for requirements)
b. Are there any wetland impacts based on at least 30% plans? Yes No
c. If Yes, state the amount and location of wetland impacts, including a total for the
project.
d. Are there any stream or channel impacts on at least 30% plans? Yes No
e. If Yes, state the amount and location of channel and/or stream impacts, including
a total for the project.
8.Required Form Attachments (see instructions for requirements)
a.A location Map
An aerial location map identifying the project limits is attached. Yes
b.A Detour Map
If a detour is required for the project then an aerial figure identifying the project area and the detour is attached. Yes
c. WetlandReview Documentation
A wetland review memo, determination checklist, preliminary wetland determination, or full delineation report/documentation has been conducted for the project and is attached. Yes
d.Site Photos
Color site photos of the project are attached. Yes No
e.Aerial Photos
Color aerial photos of the project are attached. Yes No
Checklist of Activities / ImpactsUpdated
12/21/16
Checklist of NDOT Activities / Sources of Impacts
Project Name:
Control No.:
Project No.:
Date Checklist was created: Date Checklist was last updated: Initials:
Check the “Yes” box for all activities to be included in the project.
ACTIVITY / SOURCES OF IMPACTS / To be included in Project?YES
Asphalt Patching
Bank Stabilization
Barge Staging
Bridge Deck Repair
Bridge Deck Replacement
Bridge Painting
Bridge Rail Repair/Replacement
Bridge Substructure New, Replacement, or Repair – Ephemeral
Bridge Substructure New, Replacement, or Repair – Intermittent
Bridge Substructure New, Replacement, or Repair – Perennial
Bridge Superstructure New, Replacement, or Repair – Ephemeral
Bridge Superstructure New, Replacement, or Repair – Intermittent
Bridge Superstructure New, Replacement, or Repair – Perennial
Channel Grade Stabilization Structures
Channelization, Ephemeral
Channelization, Intermittent
Channelization, Perennial
Clearing and Grubbing – Non-woody Vegetation
Clearing and Grubbing – Trees and Shrubs
Cofferdams
Concrete Pavement Repair
Crack Sealing and Joint Sealing
Culvert New, Replacement, Extension, Repair – Ephemeral
Culvert New, Replacement, Extension, Repair – Intermittent
Culvert New, Replacement, Extension, Repair – Perennial
Curb & Flume
Curb & Gutter
Detention Basin
De-watering
Drilled Shafts
Earth Shoulder Construction
Erosion Control – Barriers
Erosion Control – Erosion Checks
Erosion Control – Inlet/Outlet Protection
Erosion Control – Mulching
Erosion Control – Rolled Erosion Control
Erosion Control – Slope Interruption
Erosion Control – Traps and Basins
Erosion Control – Vegetation
Fencing
Grading Within the Hinge Point
Grading Outside the Hinge Point
Guardrail Repair, Replacement, or Installation with Soil Disturbance
Guardrail Repair, Replacement, or Installation without Soil Disturbance
Habitat Fragmentation, Modification of Connectivity
Landscaping
Lighting, Traffic and Pedestrian Signals, Dynamic Message Signs with Soil Disturbance
Lighting, Traffic and Pedestrian Signals, Dynamic Message Signs without Soil Disturbance
Microsurfacing
Milling and/or In-place Recycling
Nighttime Work with Lights
Noise Walls (Not in Water/Wetlands)
Overpass
Pavement Removal
Paving
Piers
Pile Driving – Impact
Pile Driving – Vibratory
Pile/Pier Encasement
Pipe Jacking & Casing
Pre-watering
Removal of Structures and Obstructions
Replacing a Bridge with a Culvert
Resurfacing – Fog/Slurry Seal, Armor Coat/Chip Seal, Overlay
Retaining Walls (Not in Water/Wetlands)
Rock or Gravel Surfacing
Shoo-fly
Sidewalks and Bikeways
Signs with Soil Disturbance
Signs without Soil Disturbance
Stream Channel Impact, Ephemeral
Stream Channel Impact, Intermittent
Stream Channel Impact, Perennial
Survey and Staking
Temporary Crossing, Causeway, Work Platform
Trenched Widening
Underground Utility Conduit Installation
Wetland Mitigation
List other activities that are not in Checklist: